Fillable Application Pt 1 E

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Application Pt 1 E

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The Application Pt 1 E form is 4 pages long and contains:

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  • 5 check-boxes
  • 61 other fields

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File type: PDF

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TO YOUR INSTRUCTOR
APPENDIX D
APPLICATION – PART I
COOPERATIVE WORK EXPERIENCE EDUCATION
Cerritos College, Norwalk, California
(PLEASE TYPE OR PRINT)
Name ___________________________________________ Student #: _________________________
Home Address: ________________________________________________________________________
Home Phone Number (Include Area Code): _________________________________________________
Occupational Goal: __________________________________________ Major Code: _____________
Job Title: ____________________________________________ Length of Employment: __________
Employing Firm Name:
__________________________________________________________________
Firm Address: _________________________________________________________________________
Immediate Supervisor’s Name: ___________________________________ Title: _________________
Supervisor’s Phone Number: _(_____)______________________________ Extension: ____________
*************************************************************************************
Student’s Work Schedule: Fulltime ☐ Part time ☐
Hours: Day ☐ Swing ☐ Graveyard ☐
Previous units enrolled in Work Experience at Cerritos _____________________; Other Community
College in California. ____________________
I hereby certify that the total units in Cooperative Work Experience, including this term, will not exceed
16 units earned at all community colleges in California including Cerritos College (California
Administrative Code, Section 55253). I understand I must be enrolled in 7 units including Cooperative
Work Experience Education during the fall or spring semester. (During the summer sessions I will be
enrolled in one course related to my occupational goal in addition to Cooperative Work Experience.) I
declare that my occupational goal in the Statement of Cooperation is related to my field of work, and I
understand that misrepresentation of information on this form or the Statement of Cooperation shall be
grounds for dismissal from and/or forfeiture of credit from the Cooperative Work Experience Program.
__________________________________
Student’s Signature
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Student’s Signature: _____________________________
Student’s Name: ________________________________
APPLICATION – PART II
COOPERATIVE WORK EXPERIENCE EDUCATION
PLEASE LIST MAJOR AREA COURSES COMPLETED AT CERRITOS COLLEGE:
______________________________________ ____________________________________________
______________________________________ ____________________________________________
______________________________________ ____________________________________________
APPLICATION – PART III
Write an accurate “Job Description” of your work duties. Describe your job as briefly as possible.
1. ___________________________________________________________________________________
2. ___________________________________________________________________________________
3. ___________________________________________________________________________________
4. ___________________________________________________________________________________
5. ___________________________________________________________________________________
____________________________________ Company Name: _______________________________
(Last Name) (First Name) Address: ______________________________________
Home Phone: _________________________ Phone: _______________________________________
Work Phone: _________________________ Supervisor’s Name: _____________________________
Working Hours: _______________________ Parking Instructions: ____________________________
Lunch Hours: _________________________
Best day to visit your place of employment: _________________________________________________
APPLICATION APPROVAL _____________________________________________
Instructor’s Signature
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signature
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signature
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Student’s Name: ______________________________
APPLICATION – PART IV
Draw a map showing the location of your work place. Draw the map as if you are driving from Cerritos
College to your work. Please be neat. Use ink and a ruler to print your directions and remember to make
the top of your map North.
APPLICATION – PART V
PLEASE LIST CURRENT CLASS SCHEDULE
Name of Class Instructor Room Time and Day
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Application Pt 1 E

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Completed 14 April 2020

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